Provider Audit Program

Policy Number: GP-X-029

Last Updated: Jan. 7, 2022 

Prepayment/Post-Payment Review

Blue Cross and Blue Shield of Nebraska (BCBSNE) or designated vendors acting on behalf of BCBSNE can conduct prepayment and post-payment reviews to monitor and assess the accuracy of the diagnosis and procedure coding as well as to determine the medical necessity and appropriateness of the items or services provided.  

Claims subject to prepayment and post-payment reviews include, but are not limited to:

  • All claims with allowable charges amount ≥ $200,000 received prior to Jan. 1, 2021. 
  • All claims with allowable charges ≥ $100,000 received on or after Jan. 1, 2021.  
  • All inpatient claims indicating a readmission within seven calendar days. Each readmission is reviewed in conjunction with the previous admission.  
  • All inpatient claims indicating a transfer to an inpatient facility from a lower level of care.  
  • All outlier claims as identified by the BCBSNE Provider Audit department.  
  • All inpatient interim claims.  
  • Randomly selected outpatient claims.  
  • Randomly selected inpatient claims.  
  • Randomly selected professional claims. 

BCBSNE reserves the right to require a provider to submit medical records and itemizations supporting billed items and services with the claim.